The QDR examines quality and disparities based on the six priority areas and access. The findings below provide examples of measures that showed large disparities, worsening disparities, or large improvements over time. A comprehensive list of measures improving, worsening, or staying the same, as well as disparities with reference groups and trends in disparities, can be found in Appendix B.

Trends in Quality

Quality of health care improved overall through 2014, but the pace of improvement varied by priority area.

Figure 14. Number and percentage of all quality measures that were improving, not changing, or worsening, total and by priority area, from 2000 through 2014

Priority Area

Improving

No Change

Worsening

Total (n=172)

99

56

17

Person-Centered Care (n=12)

10

2

0

Patient Safety (n=32)

21

9

2

Healthy Living (n=54)

33

17

4

Effective Treatment (n=36)

19

15

2

Care Coordination (n=31)

15

8

8

Affordable Care (n=7)

1

5

1

Key: n = number of measures.Note: Most measures are tracked from 2000 through 2014 and others begin in later years. For more information, please review Appendix B.

Trends in Person-Centered Care

Person-centered care means defining success not just by the resolution of clinical symptoms but also by whether patients achieve their desired outcomes. About 80% of person-centered care measures were improving overall. For example, overall trends from 2002 to 2014 showed significant improvement in provider-patient communication for adults who had doctor visits in the past 12 months (Appendix A, Graph 2) (AHRQ, Medical Expenditure Panel Survey [MEPS]).

Trends in Patient Safety

Ensuring patient safety means to provide care free from accidental injury due to medical care or medical errors (Kohn, et al., 2000). The QDR tracks a number of patient safety measures organized around the major health care settings that must measure, understand, and improve health care so that Americans can be cared for in a safer health care environment. Measures include hospital-acquired infections, pressure ulcers in nursing homes, inappropriate prescription medications, and hospital readmissions.

Almost two-thirds of patient safety measures were improving overall. However, no statistically significant changes overall were observed in measures such as adult hospital patients with an anticoagulant-related adverse drug event to warfarin. In 2009, the rate for this measure was 4.4% and in 2014 the rate was 4.8% (AHRQ and Centers for Medicare & Medicaid Services [CMS], Medicare Patient Safety Monitoring System [MPSMS]).

The percentage of adult patients receiving hip joint replacement due to fracture who had adverse events, which improved from 16.4% in 2009 to 9.8% in 2014 (Appendix A, Graph 3) (AHRQ and CMS, MPSMS).

The percentage of adult hospital patients with an anticoagulant-related adverse drug event to low-molecular-weight heparin and factor Xa, which improved from 5.6% in 2009 to 3.5% in 2014 (Appendix A, Graph 4) (AHRQ and CMS, MPSMS).

Trends in Healthy Living

Healthy living measures in the QDR track process measures that focus on helping individuals maintain healthy lifestyles and wellness in their communities. These include measures for clinical preventive services, maternal and child care, obesity prevention, functional status preservation and rehabilitation, and supportive and palliative care.

About 60% of healthy living measures were improving overall, including adolescent vaccination. From 2008 to 2014, the percentage of adolescents ages 16-17 who received meningococcal conjugate vaccine increased from 38.6% to 79.1% (Appendix A, Graph 5) (Centers for Disease Control and Prevention [CDC], National Center for Immunizations and Respiratory Diseases and National Center for Health Statistics [NCHS], National Immunization Survey – Teen). However, no statistically significant changes overall were observed for influenza vaccinations for high-risk adults.

About 7% of all measures showed worsening performance, including one women’s health measure and one children’s health measure. In 2000, 87.5% of women ages 21-65 received a Pap smear in the last 3 years, but in 2013, 80.7% of women reported receiving this test (Appendix A, Graph 6). From 2002 to 2014, the percentage of children ages 12-19 with obesity increased from 16% to 20.5% (Appendix A, Graph 6) (CDC, NHANES).).

Trends in Effective Treatment

Delivering optimal treatments for acute illness can help reduce the consequences of illness and promote the best recovery possible. The QDR effective treatment measures include process measures for preventive care, treatment of acute illness, and chronic disease management. Some outcome measures are also tracked in the QDR since timely treatment of acute illness and injury and meticulous management of chronic disease can positively affect mortality, morbidity, and quality of life.

More than half of Effective Treatment measures were improving. However, several areas show no statistically significant changes overall, including diabetes care, treatment for illicit drug use, and treatment for alcohol problems for people age 12 and over who needed such treatment.

Trends in Care Coordination

Care coordination is a conscious effort to ensure that all key information needed to make care decisions is available to health care consumers and providers. Care coordination is defined as the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate appropriate delivery of health care services (Shojania, et al., 2007). Coordinating basic patient information among providers is essential so that important information is not ignored, lost, or never communicated. Incomplete or inaccurate information and lack of followup care leads to confusion, higher costs, and misuse of medications, tests, and therapies for all patients, which results in poor outcomes (Carney Moore, et al., 2008).

About a quarter of all care coordination measures showed worsening performance. For example, avoidable admissions for hypertension per 100,000 population age 18 and over increased from 46.1 in 2000 to 54.2 in 2014. From 2007 to 2014, the rate of emergency department visits with a principal diagnosis related to mental health increased from 1,063 per 100,000 population to 1,391 per 100,000 population (AHRQ, HCUP, Nationwide Emergency Department Sample [NEDS]).

About half of Care Coordination measures were improving overall. Among the best performing measures were hospital patients with heart failure who were given complete written discharge instructions. In 2013, 94.6% of patients received written discharge instructions, an increase from 57.4% of patients in 2005 (CMS, Clinical Data Warehouse). The rate of admissions for angina without cardiac procedure per 100,000 population age 18 and over showed one of the largest improvements, from 81.5 in 2000 to 11.9 in 2014 (AHRQ, HCUP, NIS, SID).

Trends in Care Affordability

Health insurance is designed to protect individuals from the burden of high health care costs. However, even with health insurance, the financial burden of health care can be high and is increasing (Banthin & Bernard, 2006). High premiums and out-of-pocket payments can be a significant barrier to accessing needed medical treatment, resulting in higher comorbidity and lower quality of life (Henrikson, et al., 2017). In addition, the advent of high-deductible health plans is placing a financial burden on many people, especially those with chronic conditions (Reed, et al., 2012; Zimmerman, 2011). Ensuring health care is affordable remains an important factor in achieving access to high-quality health care.

Data presented in this report show that about 70% of care affordability measures had no statistically significant changes overall. For example, from 2006 to 2014, no statistically significant changes were observed in the percentage of people under age 65 whose family's health insurance premiums and out-of-pocket medical expenditures were more than 10% of total family income (17.5% to 16.1%) (AHRQ, MEPS).

Trends in Disparities

Although some gaps are getting smaller, disparities remain.

Measures in this report were analyzed by comparing race/ethnicity, income, and insurance status with their reference groups in order to show disparities that may exist between these groups.

Figure 15. Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group (White) in 2014-2015

Black vs. White
(n=182)

Asian vs. White
(n=163)

AI/AN vs. White
(n=93)

NHOPI vs. White
(n=50)

Hispanic vs. Non-Hispanic White
(n=168)

Better

23

55

12

12

37

Same

82

76

50

24

66

Worse

77

32

31

14

65

Figure 16. Number and percentage of quality measures with disparity at baseline for which disparities related to race and ethnicity were improving, not changing, or worsening (2000 through 2014-2015)

Black vs. White
(n=61)

Asian vs. White
(n=24)

AI/AN vs. White
(n=20)

NHOPI vs. White
(n= 2)

Hispanic vs. Non-Hispanic White
(n=54)

Improving

12

3

11

No Change

47

22

17

2

43

Worsening

2

2

0

Key: n = number of measures; AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.

Figure 17. Number and percentage of quality measures for which income groups experienced better, same, or worse quality of care compared with reference group (high income), 2014-2015

Income

Better

Same

Worse

Poor (n=123)

8

46

69

Low Income (n=122)

4

50

68

Middle Income (n=123)

3

68

52

Figure 18. Number and percentage of quality measures with disparity at baseline for which disparities related to income were improving, not changing, or worsening (2000 through 2014-2015)

Income

Improving

No Change

Worsening

Poor (n=79)

13

59

7

Low Income (n=75)

7

66

2

Middle Income (n=62)

62

Key: n = number of measures.

Figure 19. Number and percentage of quality measures for which insurance groups experienced better, same, or worse quality of care compared with reference group (privately insured), 2014-2015

Insurance

Better

Same

Worse

Total (n=139)

19

50

70

Public (n=71)

9

36

26

Uninsured (n=68)

10

14

44

Key: n = number of measures.

Overall Disparities

There were significant disparities for poor and uninsured populations in all priority areas. Figures 15-19 show that overall, some disparities were getting smaller from 2000 through 2011-2015, but disparities persist, especially among people in poor and low-income households, uninsured people, Hispanics, and Blacks.

Disparities in Patient Safety

While many patient safety measures were improving overall, there were significant disparities in other patient safety measures, including the percentage of older adults who received potentially inappropriate prescription medications. In 2014, the percentage of older adults who, in the calendar year, received at least 1 of 33 potentially inappropriate prescription medications was higher for adults with complex activity limitations (21.7%) compared with adults with neither basic nor complex activity limitations (8.2%) (Appendix A, Graph 8iii) (AHRQ, MEPS).

Disparities in Care Coordination

Although about half of care coordination measures showed improvement, the largest disparities were observed in some preventable emergency department visits. These included emergency department visits for asthma for poor children (1,515 per 100,000 population) and adults (923 per 100,000 population) compared with high-income children (549 per 100,000 population) and adults (310 per 100,000 population) in 2014 (Appendix A, Graph 9) (AHRQ, HCUP, NEDS, 2014).

Trends in these disparities also show worsening over time. From 2008 to 2014, the rate of poor adults who visited emergency departments for asthma increased from 809 to 923 per 100,000 population compared with high-income adults, who showed a decrease from 348 to 310. For poor children, the rate increased from 1,196 to 1,515 per 100,000 population compared with high-income children, whose rate remained stable (553 in 2008 and 549 in 2014) (Appendix A, Graph 10) (AHRQ, HCUP, NEDS, 2008-2014).

Similarly, significant disparities in 2014 and worsening disparities from 2007 to 2014 were observed for emergency department visits for mental health among poor adults compared with high-income adults. High rates of utilization in emergency department visits may point to challenges in coordination of care and inadequate access. From 2007 to 2014, the rate of emergency department visits for mental health increased from 1,369 per 100,000 population to 1,993 per 100,000 population among poor adults. For adults with high income, the rate increased from 763 per 100,000 population to 941 per 100,000 population (Appendix A, Graph 11) (AHRQ, HCUP, NEDS, 2007-2014).

Disparities in Care Affordability

Significant disparities persist for poor people compared with high-income people who reported they were unable to get or were delayed in getting needed medical care due to financial or insurance reasons (Appendix A, Graph 12) (AHRQ, MEPS).

Significant disparities also persist for uninsured people compared with privately insured people who reported they were unable to get or were delayed in getting needed medical care due to financial or insurance reasons (Appendix A, Graph 13) (AHRQ, MEPS).

Variation in care persisted across the urban-rural continuum in 2014-2015.

Figure 20. Number and percentage of quality and access measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group in 2014-2015, by geographic location

Geographic differences vary by priority area.

Care Coordination

Data show differences in utilization of mental health care and substance abuse treatment in large urban areas and small rural areas. High rates of utilization in emergency department visits may point to challenges in coordination of care and inadequate access.

In 2014, the rate of emergency department visits with a principal diagnosis related to mental health per 100,000 population was higher for residents of large central metropolitan areas (1,435 per 100,000) than for residents of large fringe metropolitan areas (1,163 per 100,000) (Appendix A, Graph 14) (AHRQ, HCUP, NEDS, 2014).

In 2014, residents of large central metropolitan areas (758 per 100,000) were more likely than residents of large fringe metropolitan areas (572 per 100,000) to have an emergency department visit with a principal diagnosis related to substance abuse only (Appendix A, Graph 15) (AHRQ, HCUP, NEDS, 2014).

Effective Treatment

Data show that care for cardiac conditions remains a challenge for rural areas. In 2014, residents of micropolitan areas (384.7 per 100,000) were more likely than residents of large fringe metropolitan areas (329 per 100,000) to have hospital admissions for heart failure (Appendix A, Graph 16) (AHRQ, HCUP, National Inpatient Sample, 2014, and AHRQ Quality Indicators, version 4.4).

Some measures, such as treatment for drug use, show worse performance in large suburbs. In 2015, residents of medium metropolitan areas (24.2%) and noncore areas (26.8%) who needed treatment for illicit drug use were more likely than residents of large fringe metropolitan areas (15.5%) to receive such treatment at a specialty facility (Appendix A, Graph 17) (Center for Behavioral Health Statistics and Quality, 2016, Results from the National Survey on Drug Use and Health: custom tables, Substance Abuse and Mental Health Services Administration, Rockville, MD).

Care Affordability

Finding affordable care appears to have improved in some smaller populated areas. In 2014, the percentage of people who were unable to get or delayed in getting needed prescription medicines who cited financial or insurance reasons was lower in small metropolitan areas (41.0%) than in large fringe metropolitan areas (69.8%) (Appendix A, Graph 18) (AHRQ, MEPS).

iii. Not all graphs in Appendix A are cited in this report. Appendix A contains additional measures.

Internet Citation: Quality and Disparities in Quality of Health Care. Content last reviewed July 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr16/quality.html